CMS Further Clarifies Functional Limitation Reporting Requirements

The Centers for Medicare and Medicaid
Services (CMS) yesterday further clarified the regulations on the new
functional limitation reporting requirements to include reporting on patients
who have Medicare part B as a primary insurance and those who have Medicare
part B as a secondary insurance.

CMS was mandated to collect information on
claim forms regarding beneficiaries' function and condition, therapy services
furnished, and outcomes achieved on patient function by the Middle Class Tax
Relief Act of 2012. As of January 1, all practice settings that provide
outpatient therapy services must include the functional limitation data on the
claim form. To ensure a smooth transition, CMS sets forth a testing period
January 1-July 1. After July 1, claims submitted without the appropriate
G-codes and modifiers will be returned unpaid. For additional details and
resources on these new requirements, see the FAQ under General Information on APTA's
Functional Limitation Reporting Under Medicare webpage.

Comments

Claims with the new G-codes and their respective modifiers have rejected at Noridian!! (Error Description) PAYER RESPONSE: ~ACKNOWLEDGEMENT/REJECTED FOR INVALID INFORMATION | PROCEDURE CODE MODIFIER(S) FOR SERVICE(S) RENDERED
Now we have to follow up to their own requirements.

Posted by Candice H
on 1/10/2013 6:17 PM

More explanation and details can be found on CMS's website:
http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html
As this is a significant adjustment for some outpatient clinics and documentation format, it is best to get into the groove sooner than later. Good luck to all. Hope this website link is helpful.

Posted by Jana A of A.T. Still University
on 1/11/2013 12:23 AM

unbelievable how the cuts are coming. Just got denials from VA patients end of 2012 because CMS is now investigating their claims. When we contacted VA nobody knew the reason for the denials (previous approval already received). VA person stated CMS told them to deny all claims with no reason. I guess we are working for free now, or at least that's what they expect us to do.

Posted by Craig McCulloch
on 1/11/2013 9:00 PM

I had a MS patient who had an exacerbation who could not do their home program. They denied our visits because "patient not performing home program" On my notes it stated that on the few days she had an exacerbation...wonder who's doing the review.

Posted by Nirav Patel -> >OUb>N
on 1/14/2013 1:03 PM

We are getting lots of denials as well. We got denials for claims in Oct that did not need preapproval until Dec. They said oops. Our mistake but you have to file a formal appeal. Also denials for preauthorized claims with tracking number..same thing...Have to appeal. Paperwork explosion on our end. Also lots of home health overlap refund requests. Win every appeal b/c they were discharged but what a hassle.